quality improvement overview and application to a …...quality improvement overview and application...

Quality Improvement Overview and Application to a Physician Hand Hygiene ProjectCynthia KoehnMelissa GreenLoyola University Health System

September 12, 2017

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Presentation Notes

Welcome Introduce Housekeeping

Objectives/Goals

• Today• Gain a basic understanding of Quality Improvement• Apply Quality Improvement principles/tools to a Hand

Hygiene Improvement Project• Complete a Project Charter• Identify project measures you will use to collect your

data

• Our Next Meeting• Analyze the data you have collected• Identify improvement interventions

Presenter

Presentation Notes

Your HH Quality Improvement Project will include two classroom sessions. Our objectives are:

Quality Improvement Methodology

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The quality movement can trace its roots back to medieval Europe, where craftsmen began organizing into unions called guilds in the late 13th century. In the early 20th century, manufactures began to include quality processes in quality practices. After the US entered WW II, quality became a critical component of the war effort: Bullets manufactured in one state, for example had to work consistently in rifles made in another state. The birth of total quality in the US came as a direct response to the quality revolution in Japan following World War II. Can anyone tell me who Joseph Juran or who Edwards Deming are?

Improvement Models

DMAICPhase GoalDefine • Project purpose

and scope• Measures for

data collection

Measure • Gather data

Analyze • Identify root causes

Improve • Identifyimprovement strategies to mitigate root causes

Control • Monitor new system/process

PDSA

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DMAIC and PDSA are two commonly used Quality Improvement Methodologies. Both are very similar, however DAMIC originated from Six Sigma and originated in the automobile industry. Both rely on data to identify root causes and to drive effective improvement strategies. Many times, teams make the mistake of assuming they know what the cause and jump right into making improvements. This practice often results in failed projects and wasted resources (time and money). We will be following the DMAIC model, certainly not at the same level a team of Green and Black Belts would. It is a very comprehensive approach that when followed has shown huge success.

Our Project Approach

Today – January 2018Define & Measure

• Provide background information to “Define” the problem

• Complete our Project Charter• Clearly “Define” Outcome and

Process Measures• What • How• Who

• Collect reliable data to guide your future improvement strategies

February 2018Analyze & Improve

• Identify gaps between actual and goal performance

• Determine causes of those gaps• Devise potential solutions based

on data• Identify solutions that are easiest

to implement• Test Hypothetical solutions• Implement actual improvements

Define Phase

LUMC Project Charter

Project Purpose

Measures

Scope

Schedule

Team, Financial, Executive Sponsor Approval

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Presentation Notes

One of our objective is to complete our Project Charter. This is the Project Charter Template we use at LUMC. We will be handing out hard copies for each group to complete in a bit.

Define Phase: Project Charter

PurposeWhat is the problem?How big is the problem?What is the impact of the problem?

Aim StatementIncludes goal/targets for projectSpecific to patient populationTime SpecificMeasurable

Presenter

Presentation Notes

In a few minutes, you will work as groups to develop the purpose and aim statement sections on your Project Charter. For now, Melissa is going to provide you with some background information on Hand Hygiene in Healthcare. Then she is going to provide some specific data related to Hand Hygiene.

Introduction to Hand Hygiene

History of Hand Hygiene

Ignaz Semmelweis is considered the father of hand hygiene

Semmelweis was the first to discover the effects of proper hand hygiene on mortality rates between two maternity wards

Consequences of Poor Hand Hygiene

Approximately 70% of healthcare workers and 50% of surgical teams do not routinely practice hand hygiene

A single gram of human feces (the weight of a paper clip) can contain one trillion germs

Failure to wash hands can result in hospital acquired conditions, longer lengths of stay, and increased cost

Consequences of Poor Hand Hygiene

The CDC estimates that 1.7 million patients in the US will contract an infection while receiving care. 722,000 infections will occur in a hospital setting.

Healthcare associated infections (HAIs) are associated with 99,000 deaths per year

HAIs represent an estimated $30 billion in added healthcare costs per year

Current LUMC Hand Hygiene Performance

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17

Direct Audits

Secret Shopper Observations

Target

Current LUMC Infection Rates

Loyola University Medical Center HAI Data (January 2016-December 2016)

Hospital Acquired Infection Number of Infections

Catheter Associated Urinary Tract Infections (CAUTIs) 32

Central Line Associated Bloodstream Infections (CLABSIs) 28

Clostridium Difficile (C.diff) 184

Methicillin Resistant Staph Aureus (MRSA) Bacteremia Infections 14

Class I Procedure Surgical Site Infections (SSIs) 71

Class II Procedure Surgical Site Infections (SSIs) 87

Current LUMC Infection Rates

The CDC estimates that 70% of HAI’s are avoidableLoyola University Medical Center HAI Data (January 2016-December 2016)Hospital Acquired Infection Number of Infections 70% Reduction

Catheter Associated Urinary Tract Infections (CAUTIs) 32 10

Central Line Associated Bloodstream Infections (CLABSIs) 28 9

Clostridium Difficile (C.diff) 184 55

Methicillin Resistant Staph Aureus (MRSA) Bacteremia Infections 14 4

Class I Procedure Surgical Site Infections (SSIs) 71 21

Class II Procedure Surgical Site Infections (SSIs) 87 26

World Health Organization (WHO) Guidelines

• Patient Safety• First Global Patient Safety Challenge:

Clean Care is Safer Care• Hand Hygiene: Why, How & When

World health Organization (WHO) 2009. Clean care is safer care. Tools and resources. Retrieved 5/12/17 from http://www.who.int/gpsc/5may/tools/en/

WHO HH Guidelines

Why?“Thousands of people die every day around the world from infections acquired while receiving health care”

“Hands are the main pathways of germ transmission during health care”

“Hand hygiene is therefore the most important measure to avoid the transmission of harmful germs and prevent health care-associated infections”


WHO HH Guidelines

How?“Clean your hands by rubbing them with an alcohol-based formulation, as the preferred mean for routine hygienic hand antisepsis if hands are not visibly soiled. It is faster, more effective, and better tolerated by your hands than washing with soap and water”“Wash your hands with soap and water when hands are visibly dirty or visibly soiled with blood or other body fluids or after using the toilet”“If exposure to potential spore-forming pathogens is strongly suspected or proven, including outbreaks of Clostridium difficile, hand washing with soap and water is the preferred means”


Project Charter Group Activity

Fill in the project Purpose and Aim statement on your project charter

PurposeWhat is the problem?How big is the problem?What is the impact of the problem?

Aim StatementIncludes goal/targets for projectSpecific to patient populationTime SpecificMeasurable

Define Phase: Project Charter Measures

Project Charter MeasuresOutcome MeasuresProcess Measures


Project Charter MeasuresOutcome Measures

High Level Measures that need improvement Readmission Rates Mortality Infections

Current LUMC Hand Hygiene Performance

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17

Direct Audits

Secret Shopper Observations

Target

‘Based on the ‘My 5 moments for Hand Hygiene’ URL: http://www.who.int.gpsc/5may/background/5moments/en/index.html© WorldHealthsOrganization2009. All rights reserved’

WHO HH GuidelinesWhen?

Presenter

Presentation Notes

Your project will be focusing on Physician Hand Hygiene in the patient room/setting. Currently we are only measuring IN/OUT, your project will provide the Hand Hygiene Steering Committee more specific information regarding HH.

http://www.who.int.gpsc/5may/How_To_HandRub_Poster.pdf@WorldHealthsOrganization2009


WHO 5 Moments

‘Based on the ‘My 5 moments for Hand Hygiene’ URL: http://www.who.int.gpsc/5may/background/5moments/en/index.html© WorldHealthsOrganization2009. All rights reserved’



Outcome Measure

Percent of time physicians are compliant with WHO hand hygiene guidelines while inside a patient room

Numerator: Number of times where a WHO hand hygiene moment was performed

Denominator: Total opportunities to perform a WHO hand hygiene moment

Presenter

Presentation Notes

Overall compliance rate for Physician Hand Hygiene in the Inpatient Patient Room. Example: our physician hand hygiene compliance is 75%.


Project Charter Measures

Process MeasuresSpecific steps in a process that lead to a positive or negative outcomeAssess the activities carried out by healthcare professionalsMust create operational definitions


Process Measures:Number of objects touched before WHO hand hygiene momentEach individual WHO hand hygiene moment

WHO Hand Hygiene Moment #1 Numerator: Number of times hands were washed before

patient contact Denominator: Total number of opportunities to wash

hands before patient contact

CITE


Scope of ProjectWhat are the boundaries of the project?What is the start and stop point?Is the scope manageable?

Examples of scoping to consider:AgeInpatient/OutpatientICU vs Non-ICUAdmission through ED vs. Direct Admit

Summary: Define

• Reviewed the critical role hand hygiene plays in patient safety in preventing HAI

• Reviewed LUMC’s current data on HAI and hand hygiene

• Completed our Project Charter:• Purpose, Aim and Scope

• Identified Outcome and Process Measures (key metrics)

CITE

Measure Phase

We have identified our Outcome and Process MeasuresA good data collection plan helps ensure data will be usefulEstablish baselinesDevelop operational definitions

Measure Phase: Data Collection Plan

Operational DefinitionsA clear, concise detailed definition of a measure

When collecting data, it is essential that everyone participating has the same understanding and collects data in the same way.

Operation Definition Example

0%

10%

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100%

01/2017 02/2017 03/2017 04/2017 05/2017 06/2017 07/2017 08/2017 09/2017 10/2017 11/2017 12/2016 12/2017

Hospital Wide Overall Obsevation Hand Hygience Compliance

ALL ENTRANCE EXIT LUMC TARGET

Operational Definition Example

LUMC Hand Hygiene Policy (IC-009)HH must be performed upon entry and exit of a patient room, even if patient care is not anticipated and/or if gloves are usedHH with soap and water is required when contaminated with proteinaceous or if the patient if suspected of having or has Clostridium difficile.

• Antiseptic hand gel or soap and water required• Upon entry and exit of patient room• Before ALL patient care or patient contact• Before donning sterile gloves• Before donning non-sterile gloves• After contact with inanimate objects in the immediate vicinity of the patient (i.e.,

medical equipment)• After removing gloves• When moving from one body site to another while providing care• When touching one’s own face, hair or other body surfaces

INFECTION CONTROL-Hand Hygiene Policy IC-009 available on loyola.wired

Presenter

Presentation Notes

HH must be performed upon exit and entry of a patient room, even if patient care is not anticipated and/or if gloves are used HH with soap and water is required when contaminated with blood or bodily fluids or if the patient if suspected of having or has C. diff

Operational DefinitionsProcess Measure Operational Definition

Percent of time hands are washed before patient contact (WHO Moment #1)

• Compliance will be counted if the physician washes their hands with either gel or soap and water before coming in contact with any part of the patient.

• Hand hygiene performed on entrance to the room can be counted as compliant if the physician does not touch any objects before coming in contact with the patient.

• If the patient is on isolation precautions, the provider should wash their hands before putting on gloves. The gloves should not make contact with other surfaces before coming in contact with the patient.

Percent of time hands are washed before an aseptic task (WHO Moment #2)

• Compliance will be counted in the physician washed their hands with either gel or soap and water before performing an aseptic task.

• Aseptic tasks are any tasks where sterile technique is necessary including but not limited to the insertion or removal of central lines, insertion or removal of catheters, and giving an injection.

• If gloves are used during the aseptic task, the provider should wash their hands before putting on gloves.

Operational DefinitionsProcess Measure Operational Definition

Percent of time hands are washed after body fluid exposure risk (WHO Moment #3)

• Compliance will be counted if the provider washes their hands with either gel or soap and water before coming in contact with any body fluid from the patient.

• If the provider is wearing gloves and is exposed to body fluid, in order to be compliant, the provider must remove the gloves and wash their hands with gel or soap and water before putting on a new pair of gloves.

Percent of time hands are washed after patient contact (WHO Moment #4)

• Compliance will be counted if the provider washed their hands with either gel or soap and water after coming in contact with any part of the patient.

• Hand hygiene upon exiting the room may be counted as compliant if the provider does not touch any objects or the patient before exiting the room.

• If the patient is on Contact Plus precautions, the provider must use soap and water after patient contact in order to remain compliant.

• If the provider is wearing gloves, hand hygiene must be performed once the gloves are removed.

Operational DefinitionProcess Measures Operational Definition

Percent of time hands are washed after contact with patient surroundings (WHO Moment # 5)

• Compliance will be counted if the provider washestheir hands with either gel or soap and water after contact with any object inside the patient’s room.

• Hand hygiene upon exiting the room may be counted as compliant if the provider does not touch any objects or the patient before exiting the room.

• If the patient is on Contact Plus precautions, the provider must use soap and water after patient contact in order to remain compliant.

Audits• Each group will be responsible for collecting

data on one assigned WHO Moment.• Audit tools specific to your assigned data will be

emailed to your lead to distribute to the group.• Each Medical Student will be responsible for

completing 50 audits between now and January 1st 2018.

• Only focus on one physician for each audit.

Hand Hygiene Audit Tool

Collecting the Best SampleOur Data will Guide our Improvement Strategies

Gather data throughout your workday/workweekPre identify your collect data strategy and follow

it. (i.e.., every third patient round on Mon, Wed, Fri).Document your findings as soon as possible. Do not rely on your memory at the end of the dayBe objectiveDo not guess

Presenter

Presentation Notes

Keep in mind, our improvement strategies will depend on what our data reveals. If we cannot trust that our data is reliable, we will not have the information needed to identify effective strategies when we meet in February. We spend a significant amount of time choosing our process measures and developing detailed operational definitions. Do not let the time and resources spent so far be wasted, by not investing the time to accurately gather your data.

Let’s Practice

• Collect data using your audit tool independently for the following scenarios

• As a group review a correctly completed audit tool for the scenario

• Discuss/compare any discrepancies• Identify any needed clarifications in our

operational definitions

Presenter

Presentation Notes

Now we are going to practice!. Based on our identified operational definitions, use your printed audit tool to collect data for the scenario provided. Please work independently, we will pause to compare findings after each practice scenario. Scenario One = Scenario Two = Video Clip #3 Scenario Three = Vidoe clip #8

Scenario # 1

You Observe:The Resident gels his hand as he enters the room of a patient on the medical surgical unit

While he is talking to the patient, he places his hand on the side rail of the bed. After he has answered the patient’s questions, he proceeds with auscultating her heart and lung sounds. He checks the patient’s lower extremities for edema and then covers her with the sheet

He explains the tests he plans to order

As he exits the room he gels his hands

Scenario #2: You Observe:The Attending physician gels his hands as he enters the room

As he approaches the patient, he notices fresh blood on the sheet. He dons gloves to examine the patient’s abdominal surgical dressing which is saturated with blood. He removes the dressing and discards in the waste basket. He then removes his gloves and discards in the waste basket

He returns to the bedside to finish his physical exam and answers the patient’s questions

He gels his hands as he exits the room

Scenario #3:

You Observe:The physician gel her hands upon entering the room of a patient. She explains to the patient that she will be removing her central line

She positions the patient and then opens the needed supplies onto the bedside table. She then applies gloves to remove the dressing and stabilizing device. She discards the dressing and stabilizing device and then removes her gloves and discards

She carefully applies sterile gloves and proceeds with removing the line. She applies antiseptic ointment and an occlusive dressing

She cleans up her work area, then removes her gloves and washes her hands with soap and water

Recap and Quality Improvement Project

Expectations

Recap

Gained and applied basic knowledge of QI Methodology and DMAICDeveloped a project charter and identified project measuresDeveloped a data audit tool and operational definitions

QI Project Expectations

• Each Med Student will complete 50 Audits over the next 11 weeks

• 4.5 Audits per week• Submit your audits to your group lead via email

by the 1st of the month • Group lead will email the audit data to Cindy

Koehn (cynthia.koehn@luhs) each month no later than the 15th

• Final Deadline for data submission is January 15th

mailto:cynthia.koehn@luhs

Next Steps: February

For the next session:Learn the improve and control aspects of DMAICSummarize and analyze collected dataComplete a root causes analysisMake recommendations for interventions to the Hand Hygiene Steering Committee

Questions?

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Presentation Notes

Always use this as the final slide in your presentation.

quality improvement overview and application to a …...quality improvement overview and application...

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